Transcript Chronic Disease Management

Chronic Disease Management
and the Expert Patients Programme
Chronic Disease Management
Can long term
conditions be
categorised so
neatly?
Level 3
Case
Mgt
Highly
complex
patients
Level 2
Disease
Management
High risk
patients
Level 1
Self
Management
70-80% of a
CDM pop
POPULATION WIDE PREVENTION
The Expert Patients Programme
The pilot phase 2002 - 2004
The Expert Patient Programme
A New Approach to Chronic Disease Management for
the 21st Century
 Key Recommendation
Establish a programme for developing more user-led
self-management courses to allow people with chronic
illness to have access to opportunities to develop the
knowledge confidence and skill to manage their
condition better
Self Management aims to:
• Deal with the generic consequences of conditions loss of confidence, pain and fatigue
• Improve people’s problem solving, decision making
and confidence
• Develop partnerships between patients and health
professionals
EPP Course content
2.5 hours per session
x
6 weeks
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goal setting/action planning
problem solving
exercise
symptom management
techniques
fatigue management
dealing with emotions
communication
medication
community resources
Key aspects of lay-led self-management
• Emphasis on living with condition not just managing illness
– social model not biopsychosocial
• Does not provide health information
– Generic course not condition specific
• Leader facilitates problem solving does not provide answers
– The course process facilitates group and individual learning getting
participants to draw on their own experiences
1 Senior trainer &
1 trainer in each SHA
Divided between
east and west
EPP Pilot 2002- 04
Progress so far
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15,000 people with LTCs attended an EPP course
Specialist courses piloted for parents and young people
Bi-lingual tutors are being trained
Courses delivered in Prisons, with marginalised and
ethnic minority groups
• An on line course being trialled in 2005 for people who
cannot attend community groups.
Volunteer
Tutors
900
Courses
1550
Participants
15,000
98% of Primary Care Trusts taken part
Puts people back in control
"The most important thing is the
confidence the course has
given me –
I would never have dreamed of
training to lead a course like this
before –
now I want to share the
techniques with other people."
Alison - County Durham
EPP emerging trends
• 45% felt more confident that common symptoms would no
longer interfere with their lives
» Pain, tiredness, depression, breathlessness
• 38% felt that such symptoms were less severe 4 – 6
months after completing the course
• 33% felt better prepared for consultations with health
professionals
EPP monitoring data N = 1000
Jan 03 – Jan 05
EPP emerging trends
Significant reductions in service usage
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7% reductions in GP consultations
10% reductions in Outpatient visits
16% reductions in A&E attendances
9% reductions in Physiotherapy use
EPP monitoring data N = 1000
Jan 03 – Jan 05
EPP emerging trends
• 50% of participants live with 3 or more LTCs
• Over 94% of those who took part felt supported and
satisfied with the course
• Many positive comments made about the course but
people also want longer term support to build on the
progress they have made to help them re-establish
themselves in society as confident self managers.
EPP monitoring data N = 1000
Jan 03 – Jan 05
The Expert Patients Programme
Mainstreaming 2004 - 2006
Future for EPP
Local
• A mainstream NHS service available in every PCT
• Self-management support commissioned locally by PCTs
according to need and availability
• Integrated with other services locally
National
• Central support including robust QA
• Developments - EPP Online
• Part of a wider Public Health agenda
National : Training and quality
assurance framework
Local: Integration with other services
• Range of different services available for different
conditions in primary and secondary care:
– Pain management
– DESMOND / DAFNE
– Cardiac Rehabilitation
– COPD programmes
• Services provide different care pathways
Patient newly diagnosed or
condition changes
Professionally led disease specific
education and self care skills
Does patient have the support and
confidence to implement changes and
follow care plan?
No
Attend EPP course +
Information given on
local support groups,
national & local
organisations
Yes
Attends routine appointment with
practice nurse/out patients.
Is care plan working ?
No
Attend EPP
course
No
Consider
specialist support
case management
Yes
Does patient now have confidence to
self- manage condition?
Yes
No further action, patient will have
necessary skill and knowledge to alert
care team if condition changes.
What really happens to people?
Real challenges
We need to understand more about :
– the impact of long term conditions
– the impact of multiple long term conditions
– what we really need to do to support people to
become effective self – managers
Qualitative research
• People with long term conditions emerging as effective
self managers describe having been on a journey.
• Long term conditions can cause a gradual disintegration
of the person’s sense of self before beginning a long
rebuilding process to establish themselves in society as
confident self managers.
• How can we really support them through this?
“The real epiphany is the realisation that all
patients self manage, all the time. If health
professionals act in a way that undermines
people’s coping skills, then they can expect
to see patients calling on their services with
increasing frequency.”
Coulter and Elwyn 2002 BJGP 10/2002 Quality Supplement s23
Thank you!
Patrick Hill
Clinical Governance
Support Team
[email protected]
www.expertpatients.nhs.uk